New prevention strategies - from research to reality

From male circumcision to vaccines, technologies old and new are being explored in the HIV/AIDS response, in the hope that science will complement attempts to alter human behaviour. But speakers at South Africa's third national AIDS conference highlighted the many questions that remain unanswered regarding these promising new technologies and interventions.

A lively debate led by a panel of researchers, activists, journalists and scientists on Tuesday, centred around how these technologies might be implemented once the results of study trials confirm their efficacy.

A number of large-scale research trials with major implications for HIV prevention will be wrapping up in South Africa over the next couple of years.

By the end of this year, results from a large-scale trial of the microbicide, Carraguard - sponsored by the Population Council - will be available. Also in 2007, a study into the effectiveness of diaphragms in preventing HIV will deliver its findings and another looking at the impact of treating herpes, a sexually transmitted infection that has been associated with a higher risk of HIV transmission.

Results from two other microbicide trials taking place in South Africa and one looking at the use of antiretroviral drugs to prevent HIV infection (an approach called pre-exposure prophylaxis, or PrEP) are expected in 2008.

"We are in store for lots of news, and it won't all be good," Prof Salim Abdool Karim, another researcher with CAPRISA, warned delegates on the first day of the conference. He said that not enough was being done to implement the technologies we already know work such as nevirapine to prevent mother-to-child HIV transmission, an intervention that is still only reaching a fraction of pregnant women in South Africa.

Male circumcision, an old, if controversial, custom, has recently shown around 60 percent effectiveness in reducing HIV transmissions. Addressing delegates on Wednesday, Prof. Bertran Auvert, who published some of the first promising results from a male circumcision trial conducted in South Africa in 2005, urged leaders to act on the evidence and the recommendations of international agencies such as the World Health Organisation.

"We need hope and male circumcision is part of this hope," he said. "Now we have to transform it into reality."

Implementing new prevention technologies

Transforming trial results into a product or intervention that anyone can access is a long and complex process which, according to some of the panellists speaking on Tuesday, should begin as early as possible.

Issues of acceptability and cost effectiveness can be studied and communities can be educated, but post-trial access to new technologies remains problematic.

"A lot of these products aren't going to be made by big pharma [major pharmaceutical companies]," pointed out Glenda Gray, co-director of the Perinatal HIV Research Unit in Johannesburg. "There's not enough planning that occurs around how and who will manufacture them."

For interventions like male circumcision, government action will be the key. Auvert noted that six countries in the region have already begun implementing mass male circumcision programmes. Gray expressed disappointment that South Africa was not among them and was surprised activists have so far remained silent on the issue.

Implementation of new prevention technologies is also likely to come up against fears they will lead to increased risk behaviours. According to Auvert, such fears are not proven and can be avoided with proper counselling and by continuing to promote more traditional prevention methods such as partner reduction and condoms.

Research into making male and female condoms more appealing to reluctant users was an important area that was often over-looked according to Prof. Helen Rees of South Africa's Reproductive Health and HIV Research Unit.

Speaking at the opening of the conference on Tuesday, UNAIDS Executive Director Dr Peter Piot, singled out HIV prevention as the biggest priority in HIV/AIDS efforts globally and in South Africa. Piot described South Africa's new Strategic Plan target of reducing new HIV infections by 50 percent over the next four years, as "ambitious, but absolutely necessary."